Doctors and nurses need to learn how to treat dying with respect and
compassion says Nice, as it admits junior doctors too often left to make
'snap' end of life decisions alone.

Junior doctors must not be left alone to make “snap” decisions on end of life care, health watchdogs have said.

The new guidance from the National Institute of Health and Care Excellence (Nice) attempts to replace the discredited Liverpool Care Pathway with a more “individualised” approach to care of the dying.

The pathway is being phased out amid concern that patients were being denied water – and some pushed to an early grave - by the withdrawal of fluids and treatment.

The new guidance says patients must be encouraged to drink if they can, with warnings from Nice that doctors and nurses must put “respect and compassion” first.

"You don’t need a lot of training to encourage people to show respect and give compassionate care"

Prof Sam Ahmedzai, the University of Sheffield

The watchdog said there was "no excuse" for individual doctors - especially junior staff, being left to take “snap” decisions about matters of life and death.

Prof Sam Ahmedzai, emeritus professor of palliative medicine at the University of Sheffield, and one of the authors of the guideline, said any changes in the treatment of the dying must be taken in consultation with senior staff.

"If the person that thinks someone is dying - it could be a junior doctor in the hospital in the middle of the night with no-one to turn to - they should seek advice from a more experienced colleague," he said.

"There is no excuse for individuals making decisions about whether someone is dying and not taking advice."

Warning of a “postcode lottery” in current access to 24/7 specialist palliative care, Prof Ahmedzai said it was important for junior doctors to be able to get advice every day of the week – even if it was only over the phone.

Care of patients believed to be dying should be reviewed daily, Nice said - with doctors instructed to respond to any signs of improvement in the patient.

Although the pathway was supposed to be phased out last year, Prof Ahmedzai said he was fearful that in some hospitals, staff were “burying their heads in the sand” and continuing to follow the much criticised protocols.

He said staff needed to be “more respectful” of the patients in their care.

“You don’t need a lot of intensive scientific training to encourage people to show respect and give compassionate care,” he said.

He criticised the attempt in the guidance to identify “signs” that a person might be dying, saying once patients were “diagnosed” as facing death it inevitably meant their treatment was changed and their death more likely.

Nice said the changes were a significant shift which aimed to put the needs of the patient first.

"The main thing that is different is that we are saying we would want to have an individualised approach rather than applying a blanket approach, as would apply using the LCP in an unthinking way,” Prof Ahmedzai said.

The LCP was phased out last year after an expert review found a "tick-box" culture was leading to dying people being put on the pathway without the knowledge of their families.

Hospitals were being paid millions of pounds to reach targets for the numbers of patients dying on the pathway.

Families criticised decisions which led to their loved ones having nutrition and fluid withdrawn or receiving such heavy sedation that they could not be roused for a drink.

The new Nice guidance echoes some principles of the pathway, with a stop on invasive investigations and treatments if they would not help those who are dying.

But it says doctors must encourage patients to drink if they can, and consider introducing fluids via a drip if it may relieve uncomfortable symptoms for the dying patient - such as a severe dry mouth or delirium.

However, the team said there is very little evidence on whether giving fluids via a drip can extend life or shorten it.

They also pointed to some risks from hydration of the dying, such as bodily swelling in a person whose body is unable to process the fluid properly.

The pathway was axed following a review led by Baroness Neuberger, which said patients “should be supported with hydration and nutrition unless there is a strong reason not to do so”.